Vaginal Prolapse

Vaginal Prolapse Causes & Diagnosis

A vaginal prolapse is a weakness around the vagina that allows the uterus, rectum, bladder, urethra, small bowel, or the vagina itself to fall from their normal positions. In and around a woman’s vagina is a support network of muscles, ligaments, and skin, all holding organs, tissues, and structures in place in the pelvis. If parts of this system weaken or break, these can fall, or prolapse, and if neglected they can fall farther and farther into the vagina or even through the vaginal opening.

Vaginal prolapse can affect sexual and bodily functions such as urination and defecation and can also result in pelvic pressure and discomfort as common symptoms. Some women are candidates for nonsurgical treatment, while for many others, surgery is the best option.

Approximately one-third of women develop some degree of vaginal prolapse, usually after menopause, childbirth, or a hysterectomy and usually after age 40. Some do not experience any symptoms, while many women who do experience symptoms are too embarrassed to seek treatment.

Symptoms of vaginal prolapse

The symptoms of prolapse vary depending on the type, and some women experience no symptoms. The most common symptom is the sensation that something in the vagina is out of place, sometimes accompanied by a protrusion or pressure in the same area. General symptoms include:

  • Recurrent urinary tract infections
  • Pressure in the vagina or pelvis
  • A lump at the opening of the vagina
  • A decrease in pain or pressure when reclining
  • Painful intercourse

Symptoms can also be specific to certain types of prolapse:

  • Urinary stress incontinence is a common symptom of a cystocele. Constipation is the most common symptom of a rectocele.
  • Difficulty emptying bowel may indicate an enterocele, vaginal vault prolapse, or prolapsed uterus. Some women with this symptom discover they have to push their fingers against the back wall of the vagina to evacuate the bowel – a technique known as splinting.
  • Difficulty emptying bladder could be symptomatic of a cystocele, urethrocele, enterocele, vaginal vault prolapse, or prolapsed uterus.
  • Pain that increases during long periods of standing could be the signs of an enterocele, vaginal vault prolapse, or prolapsed uterus.
  • Protrusion of tissue at the back wall of the vagina is a common symptom of a rectocele.
  • Protrusion of tissue at the front wall of the vagina can indicate a cystocele or urethrocele.
  • Enlarged, wide, and gaping vaginal opening is a common symptom of a vaginal vault prolapse.           

Kinds of vaginal prolapse

  • Cystocele is a falling of the bladder, caused by a prolapse of the front wall of the vagina. When this happens, the bladder can prolapse into the vagina, and usually the urethra also prolapses (called a urethrocele). A prolapse of both the bladder and urethra is known as a cystourethrocele. Urinary stress incontinence is a common symptom of this condition.
  • Rectocele is the prolapse of the rectum, which occurs as a result of a prolapse of the back wall of the vagina. The rectal wall pushes against the vaginal wall and creates a bulge, which can be noticeable during bowel movements.
  • Enterocele is a herniated small bowel, the result of a weakening of the upper vaginal support structure.  Enterocele, which usually occurs after a hysterectomy, is the result of a separation of the front and back walls of the vagina, allowing the intestines to push against the vaginal skin.
  • Prolapsed uterus involves a weakening of a group of ligaments at the top of the vagina, causing the uterus to fall. In turn, this commonly allows both the front and back walls of the vagina to weaken. There are four stages of uterine prolapse:
    • First-degree occurs when the uterus droops into the upper portion of the vagina.
    • Second-degree takes place when the uterus falls into the lower part of the vagina.
    • Third-degree prolapse is defined by the cervix, located at the bottom of the uterus, sagging to the vaginal opening. Sometimes the cervix protrudes outside the body in a condition known as procidentia, or complete prolapse.
    • Fourth-degree is the stage in which the entire uterus protrudes entirely outside the vagina. This condition is also called procidentia, or complete prolapse.
  • Vaginal vault prolapse often occurs after a hysterectomy and the surgical removal of the uterus, which supports the top of the vagina. As the top of the vagina falls toward the vaginal opening, the vaginal walls begin to weaken, and the top of the vagina may protrude out of the body through the vaginal opening. A vaginal vault prolapse often accompanies an enterocele. About one in ten women suffer a vaginal vault prolapse following a hysterectomy.

Vaginal Prolapse Diagnosis & Treatment

Very rarely is a woman’s life in danger from a vaginal prolapse, although prolapses usually get worse with time. For this reason, it’s wise to act promptly when symptoms first appear.

The best way to diagnose vaginal prolapse is through a physical examination and a review of the woman’s medical history. Usually a physician examines each section of the vagina separately, requiring the woman to sit upright to make any prolapsed tissues easier to find.

Cystocele or rectocele are more easily discovered by a physical examination than are vaginal vault prolapse or enterocele. The examining physician may use a variety of tests for diagnosis, including a urodynamics procedure, an exam of the urethra-bladder neck, and an investigation of the strength of the pelvic floor.

The urologist may also order a magnetic resonance imaging (MRI) scan, an ultrasound exam or conduct cystourethroscopy, in which a small tube is inserted into the urethra for internal viewing of the urethra and bladder.

Some women are candidates for nonsurgical treatment, including women who are not sexually active, cannot undergo surgery, or experience few symptoms. These women may benefit from estrogen replacement therapy to help strengthen vaginal muscles.

For others, surgery is likely the best option. Today laparoscopic surgery is common for securing the vaginal vault after a hysterectomy and correcting some types of vaginal prolapse such as enteroceles or uterine prolapses.

Non-surgical treatments

Physical therapy can help strengthen the muscles in the pelvis of a sufferer of vaginal prolapse. There are two kinds:

  • Biofeedback employs a sensor to monitor muscle activity in the vagina and on the pelvic floor. Certain exercises can strengthen these muscles, sometimes enough to reverse or relieve symptoms. In addition, the sensor can monitor muscular contractions during the exercises, indicating to a physician if the exercises might be effective.
  • Electrical stimulation involves a probe which a physician applies to targeted muscles within the vagina or on the pelvic floor, delivering small electrical currents. The electricity causes the muscles to contract and strengthen.

Surgery for vaginal prolapse

Surgical treatments for vaginal prolapse vary with the type of prolapse and usually require from two to four days of hospitalization. After surgery, a patient should avoid heavy lifting for from six weeks to two months.

A surgeon operating for cystocele and rectocele works through the vagina, usually with an incision in the vaginal wall in order to push the organ up and back into place. The surgeon then secures the vaginal wall to fix the organ in its normal position and next removes any excess tissue before closing the vaginal wall. If the patient is suffering from urinary incontinence, the surgeon may need to support the urethra through a procedure called a bladder neck suspension.

For vaginal vault prolapse, which takes place high in the vagina, a surgeon may work through either the vagina or abdomen, the latter being for severe cases. In most surgeries of this type, the surgeon uses a technique called a vaginal vault suspension, in which the vagina is attached to strong tissue in the pelvis or to the sacrum, a bone at the base of the spine.

In the case of a prolapsed uterus, women who are postmenopausal or do not want to have more children usually undergo a hysterectomy. The common approach for this procedure is through the vagina.

Contact us to learn more about diagnosis and treatment options for vaginal prolapse or to schedule an appointment with our board certified urologists.